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Presenting the Medial KneePresenting the Medial Knee
7 Workshop Objectives
1. You will get a review of the anatomy of the medial knee
2. You will get a review assessment techniques for injuries to the medial knee
3. You will pick up a tip or two on assessment4. You will pick up a tip or two in teaching this topic5. I will introduce research that is important to ME 6. I will get you thinking MY way7. Leave with the feeling WE have not wasted 45
minutes
Anatomy Review of the Medial Knee
BonesTendonsLigamentsMeniscus
Injury to the Medial KneeSprains and Strains
Assessment make a clinical judgment about the degree of injury
1st degree2nd degree Sprains and Strains
3rd degreeGOALS are based on the degree of injuryMedical referral is based on the degree of injury
Meniscal TearsOther (bursitis, nerve involvement, etc.)
MCL Sprains - Epidemiology
“The MCL is the most commonly injured ligament…”(Ireland, 1999, JAT)
MCL most common knee injury in soccer and basketball (Arendt, 1999, JAT)
The MCL sprain is the most prevalent knee injury in the general population (Add ACL and MCL = 90% of knee injuries). Miyasaka KC, Daniel DM, Stone ML, Hirshman P. The Incidence of Knee Ligament Injuries in the General Population. The American Journal of Knee Surgery. 1991; 4 (1):3-8.
500 knee injuries frequency of knee injuries: ACL, 63% MCL, 44% PCL, 7% LCL, 4%
Combination Injuries Meniscal Tears, etc. Meister BR, Michael SP, Moyer RA, Kelly JD, Schneck CD. Anatomy of kinematics of the lateral collateral ligament of the knee. AJSM. Nov-Dec 2000; 28 (6):869-878.
Evaluation and Assessment of Medial Knee Injuries
HISTORYINSPECTION – OBSERVATIONPALPATIONSPECIAL TESTS
PROM, AROM, MMTStress TestingEtc.Arthrometry
The LigMaster
The evaluation relies on the expertise of the clinician to assess the MCL sprain given subjective information and performing more objective special (stress) tests.
Evaluation of the Medial KneeHISTORY
What happened/MOI?Direct blow from the side CollateralsTorsion, rotation, “twisting” Cruciates, Collaterals, Menisci
Noises?Sensations?
“Giving way” Tendonitis or Meniscus“Sharp/Knife-like Under Patella” Chondromalacia“Numb” Nerve (burning, tingling, etc.)
UH OH!!UH OH!!
MOI = Blow to the outside of the knee with or without torsion
Arnheim & Prentice, Principles of AT, 9th ed
Evaluation of the Medial KneeHISTORY
When did it happen, onsetPMHSensations felt – PAIN?
Provocation, Quality, Radiating/Referred, Severity (1-10), TimingPin-Point-Pain
Training, surfaces, mileage (10% rule), shoes, etc.
Evaluation of the Medial KneeOBSERVATION
Compare BilaterallyGait
FWB & PWBAntalgic gaitGait deviations
DeformitySwelling, edema, effusion, ecchymosisAtrophy
Evaluation of the Medial KneePALPATION
Palpate bones –compare bilaterally
R/O fx &/or dislocationIF FX or DISLOCATION IS SUSPECTED
splint (ice), MD Referral
Evaluation of the Medial KneePALPATION
Pes anserinus tendons = Sartorius, Gracilis, Semitendinosus
+ Semimembranosus
Evaluation of the Medial KneeRANGE OF MOTION
Can palpate tendons at this timeStabilize legs to isolate jointsCompare bilaterallyAROM PROM GoniometerMMT Make Test or Break Test
Evaluation of the Medial Knee SPECIAL TESTS
Anterior Drawer Test = ACL stabilitySlocum Drawer Test – adds rotation to ADTEx Rot AMRI (ACL + MCL + PMC)
Posterior Drawer Test = PCL Huston’s Test = adds rotation to PDTInternal Rotation PMRI (PCL + MCL + AMC + POL)
ACL decreases ant mvt of femur (86% and medial displacement (30%)
PCL decreases post mvt of femur (90%) and lateral displacement (36%)
Arnheim & Prentice, Principles of AT, 9th ed
15° External Rotation
Evaluation of the Medial Knee - SPECIAL TESTS
Valgus Stress Test
In 0 ° (full extension) = MCL + ACL, PCL, PM capsule, POL, etc.)And somewhere between 5 - 30°flexion = MCL and medial capsule Arnheim & Prentice, Principles of AT, 9th ed
Amount of opening at the joint during valgus stress test compared to the unaffected knee
0-5mm = mild 1+ (very little instability, tenderness, firm end point)5-10mm = mod 2+ (instability in flexion and pain!)>10mm = severe 3+ (instability even in extension, no end point)
Evaluation of the Medial Knee - SPECIAL TESTS
Valgus Stress Test
Special Tests - Meniscal TearsMcMurray’s Test: Ex rotation of tibia + valgus stress extension of the knee click or pain over medial meniscus =+
Apley’s Compression/Distraction Tests
Fox Test
Arnheim & Prentice, Principles of AT, 9th ed
Evaluation of the Medial KneeSPECIAL TESTS
Patellar TestsApprehension Test –Subluxation, DislocationPatellar/Femoral Compression Test (Clark’s Sign) & Crunch TestQ Angle Measurement
Plica Test Functional and Sports Specific Tests
Evaluation of the MCL Summary
The severity of MCL injury is based on point tenderness, swelling over the soft tissue, and findings gained by performing special tests. Evidence Based Practice My Dissertation
Questions
Does Wolff’s law apply to ligaments? “Bone and soft tissue will respond to the physical demands placed on them, causing them to re-model or realign along lines of tensile force”
Prentice, W. (2004). Rehabilitation Techniques, pg. 41.
Is a person’s left leg and right leg the same?Do people have a dominant leg? Do athletes?
More Questions
Do males have stronger bones, tendons, and/or muscles than women?Do males have stiffer ligaments than females? So stronger joints?What if the MCL is the same in males and females? Does that mean the ACL is the same in males and females?
Medial Collateral Ligament
Attachments:Just inferior to the adductor tubercle on the femoral epicondyleMedial tibial flare
2 PortionsSuperficial = Tibial collateral or MCLDeep = medial ligament or capsular ligament attaches to medial meniscus
Medial Collateral Ligament
Deep portion of MCL attaches to medial meniscus.
Posterior aspect of superficial MCL blends into deep PCL and semimembranosus muscle, which also attaches to the medial meniscus
Medial Collateral Ligament
Functions:Valgus stressTibial external rotationTibial anterior translation
Different knee positions matter!
Knee position changes the function of the MCL
In extension: Superficial MCL is taut
In flexion: anterior MCL is taut, posterior is slack
MCL SPRAINThe Valgus Stress Test
The common MOIs for injury to the MCL Direct hit (force) on the outside of the knee (valgus stress)Outward rotational force
Therefore, the position of the knee when performing the Valgus Stress Test is:1. Full Extension2. Flexed 20°
25° How much and why?30°
25° flexion to isolate the MCL
References Norkin and Levangie, 1992.
F.A. Davis2002
Evaluation of Orthopedic and Athletic Injuries (2nd Ed.)
2. Starkey, C., Ryan, J.
Add internal rotation of tibia = ↑ ACL and PCL stress and ↓ stress to MCL
Add external rotation of tibia = ↓ stress on PCL
Flexed = MCL + PCL, Medial Capsule, Post. Oblique Lig.
Full Ext = MCL, PMC + ACL, PCL, POL, medial Quads
20 - 30°flexionNone
Human Kinetics2000
Assessment of Athletic Injuries
1. Shultz, S., Houglum, P., Perrin, D.
DEGREES OF
FLEXIONREFPUBLISHERTEXTBOOKAUTHOR(S)
“…knee flexed just enough so that it unlocks from full extension”
No references
Appleton-Century-Crofts1976
Physical Examination of the Spine and Extremities
5. Hoppenfeld, S.
20 – 30° flexion
References McClure, Rothstein, and Riddle, 1989 & Smith and Green, 1995
Slack Inc.2002
Special Tests for Orthopedic Examination (2nd Ed.)
4. Konin, J., Wiksten, D., Isear, J., Brader, H.
30° flexion in text, 20 - 30° in Table (page 528)
References Lynch and Henning, 1995.
McGraw-Hill 2000
Principles of Athletic Training, (10th Ed.)
3. Arnheim, D., Prentice, W.
DEGREES OF FLEXION
REFPUBLISHERTEXTBOOKAUTHOR(S)
The LigMaster Device and Software
Sport Tech, Inc., Charlottesville, VAJoints: ankle, knee, shoulder, elbowTelos device used in radiology for Graded Stress Radiography (GSR)
The LigMaster Device and Software
Pressure Actuator set at joint lineLinear decoder detects displacementPlots force/strain curve
SLOPEF = Ao EModular elasticity = stiffness laxity
Left Vs. Right
LigMaster Data Summary
Name: PAA 38, Last seen: Thu Jul 01 2004
Test: Right Knee MCL Thu Jul 01 2004 08:32 Title: full ext 1
Test analysis: x-intercept = 0.02 Slope = 19.98
Comparison: Left Knee MCL Thu Jul 01 2004 08:41 Title: full ext 3
Comparison analysis: x-intercept = 0.04 slope = 20.19
Knee MCL analysis: Test ligament slope 1.04% less than comparison
Forc
e, d
N
λ−1/λ2Ligament Strain:
Apparent Ligament Extension, mm
PAA 38,
0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.850
1
2
3
4
5
6
7
8
9
10
11
12
13
14
5 10 15 20 25 30 35 40
TestRight Knee MCLJul 01 2004 08:32
full ext 1
ComparisonLeft Knee MCLJul 01 2004 08:41full ext 3
Same knee, one flexed 20°LigMaster Data Summary
Name: PAA 38, Last seen: Thu Jul 01 2004
Test: Right Knee MCL Thu Jul 01 2004 08:32 Title: full ext 1
Test analysis: x-intercept = 0.02 Slope = 19.98
Comparison: Right Knee MCL Thu Jul 01 2004 08:36 Title: 20 d flex 2
Comparison analysis: x-intercept = 0.01 slope = 16.97
Knee MCL analysis: Test ligament slope 17.72% greater than comparison
Forc
e, d
N
λ−1/λ2Ligament Strain:
Apparent Ligament Extension, mm
PAA 38,
0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.850
1
2
3
4
5
6
7
8
9
10
11
12
13
14
5 10 15 20 25 30 35 40
TestRight Knee MCLJul 01 2004 08:32
full ext 1
ComparisonRight Knee MCLJul 01 2004 08:3620 d flex 2
Position of Knee Study Results
Overall:Overall: FF(4,44)(4,44) = 19.57, = 19.57, PP< .001< .001TT--Tests:Tests: 0 0 --1010°° no differenceno difference0 0 --1010°° & 15& 15°° -- 2020°° differentdifferent1515°° -- 2020°° no differenceno difference* = diff from 0* = diff from 0--1010°°
17.22 17.22 ++ 2.552.552020°° **
18.53 18.53 ++ 2.172.171515°° **
19.83 19.83 ++ 2.222.221010°°
21.00 21.00 ++ 2.172.1755°°
21.51 21.51 ++ 2.882.8800°°
Mean Mean ++ SDSDKnee PositionKnee Position
0
5
1 0
1 5
2 0
0 d5 d1 0 d1 5 d2 0 d
**
Summary
Medial knee injuries are prevalent in athletics, the MCL is the most often sprained ligamentEvaluation and assessment of medial knee injuries includes taking a thorough history, good observation and palpation skills, and being able to perform special testsThe Valgus Stress Test seems to be a valid test and fairly reliable but authors don’t agree on the specifics of itArthrometry may be helpful in gaining more objective information regarding the extent of injury and healing of a ligament after injury Management and rehabilitation should follow an established progression and should be based on the principles of tissue healing. Return to Play should be determined by criterion which includes both subjective and objective information
Workshop Objectives
Review the anatomy of the medial kneeReview assessment techniques for injuries to the medial
kneePick up a tip or two on assessmentPick up a tip or two in teaching this topicIntroduce research that is important to me To get you thinking my wayLeave with the feeling we have not wasted 45 minutes
ResourcesAndrews, J., Harrelson, G., Wilk, K. (2004). Physical Rehabilitation of the Injured Athlete,3rd Ed. , Philadelphia: SaundersArnheim,D., Prentice, W. (1997). Principles of Athletic Training, Ed 9, Boston: McGraw-Hill Company. Photo CD AND 10th Edition (2000) TextBaker, C. Editor (1995).The Hughston Clinic Sports Medicine Book, Baltimore: Williams & WilkinsDenegar, C., Saliba, S., Saliba, E. (2004) Therapeutic Modalities from J. Hertel and C.R. Denegar, 1998, “A rehabilitation paradigm for restoring neuromuscular control following athletic injury,” Athletic Therapy Today 3 (5): 13–14.Konin, J., Wiksten, D., Isear, J., Brader, H. (2002). Special Tests for Orthopedic Examination, 2nd Ed. Thorofare, NJ: SLACK, Inc.Prentice, W. (2004). Rehabilitation Techniques, 4th Ed. Boston: McGraw-Hill CompanyShultz, S., Houglum, P., Perrin, D. (2000). Assessment of Athletic Injuries, Champaign, IL: Human KineticsStarkey, C. Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries, 2nd Ed.Philadelphia: F.A. Davis CompanyVanDeGraaff, KM, Crawley, JL (1999). A Photographic Atlas for the Anatomy &Physiology Laboratory. Englewood, CO: Morton Publishing Company.WWW.Despair.com